Monday, November 21, 2011

Trigger points as a cause of back pain

Progress and growth are impossible if you always do things the same way you’ve always done them.
Backs are among the trickiest things in the world, especially when they start playing up. There are many, many different theories about what causes back pain. Logically, this clearly demonstrates that no-one really knows whether they are right or wrong in diagnosing its causes. They cannot all be right but neither can they all be wrong. But no-one knows for certain.

In my work as a general practitioner administering Nesfield’s Treatment, I see a wide variety of people of both sexes suffering the agonies of back pain. They represent a broad assortment of ages, with differing pain levels, pain locations and physical signs; disc prolapsed and bone degeneration. I am also able to examine their X-rays, CAT and MRI scans, and learn about their various previous diagnoses, or medical opinions, and treatments.

This information services mainly to confirm my opinion that the cause of back pain constitutes one of the great unsolved mysteries of the medical world. It has also guided me down my own path seeking an answer, or answers, to the causes of the affliction and, of equal importance, to find out why Nesfield’s Treatment works.

Soon after I started using the treatment, I became aware that Dr Rees’ procedure was controversial and that there had been a powerful backlash against it by mainstream Australian medicine. I had never heard of it during my medical training and in my subsequent work as a general practitioner. Yet, here I was, actively performing the procedure and achieving an exciting degree of success.
In tracing the backlash against the procedure, and reading, or hearing, what its critics had to say, I began to suspect that the reasons quoted by Dr Rees as to the mechanism of pain relief may well have been incorrect. From the time he first performed the treatment, Dr Rees had stated that he ‘cut the nerve supply to the zygapophyseal joint’ in effect a denervation, or nerve-cutting process. I concluded that, although the procedure was undoubtedly a highly effective treatment for some types of back pain, Dr Rees was wrong about why it worked; the scalpel he used was simply not long enough to reach the nerve supply to the zygapophyseal joints at the back of the vertebra.

Most patients I see have had many different opinions as to the diagnosis of their back pain and many different recommendations as to the treatment of their pain. Each practitioner believes that their advice is appropriate and that their treatment will help the patient. However, these recommendations often vary enormously. With such a diversity of opinion, it is likely that all theories have some fundamental flaws and that, in most cases, we do not know the cause of pain.
In short, I believe the critics of the procedure were right not to believe Dr Rees’ theory why the procedure was successful. But they were wrong to believe that it did not work.
In accepting this, and setting out to find my own answers, I arrived at one simple question. Was there something that most patients with chronic back pain had in common? If I could answer that, I might begin to understand why the procedure worked.

To my pleasant surprise, after studying my files, the answer was yes. I found that the vast majority of my patients suffering chronic back pain had tender areas in muscles around the vicinity of their pain – trigger points. Most patients are well aware of the location of these trigger points. More significantly, they know that if the points are massaged hard enough, some temporary pain relief usually follows.

My theory would best describe trigger points as clusters of sensory fibres. They are akin to outposts from major nerves within the body, just as capillaries are end branches of arteries. These nerves are not vital to the effective functioning of the central nervous system. Although trigger points are not visible to the naked eye and look identical to surrounding tissue (except under intense magnification) they are recognised medically. They are known variously as Points of Travell, Distil Points of Russell and Points Apopysaire. They have been listed in medical text books for a good number of years.
In recognising the commonality of trigger points in back pain sufferers, I realised that most non-surgical back pain treatments also target these trigger points e.g. physiotherapy, chiropractic, osteopathy, massage, acupuncture, injection and traction.
Most of the above treatments target these fiery little trigger points and apply diverse forms of stimuli to them to obtain varying degrees of pain relief. Most of the other methods, however, obtain only temporary alleviation whereas my method, when successful, appears to be permanent.
Recognising that trigger points are the common factor in chronic back pain and also the target of virtually all non-surgical back pain treatments, I concluded that trigger points were somehow intimately involved in the production of back pain. I also concluded that, in any given patient, there seemed to be two possible sources of pain. One pain, in my opinion, certainly emanated from the vertebral column complex – bones, discs, ligaments and nerves. The other pain came from the trigger points. Further, I concluded there was probably a connection between the vertebrae and the trigger points, with pain transmission from the trigger points to the central nervous system.

Again I compared my trigger point treatment with other forms of therapy – massaging, puncturing, stretching, pressure, ice, needling or injecting. I realised that, in reality, I was merely taking all of those treatments one significant step further. By surgically invading the painful trigger points and sweeping through them with a fine scalpel, I was physically entering a pain transmission or generation zone and probably short-circuiting it – permanently. It was logical to assume that I was dividing, or separating, sensory fibres. That, I believed, was why it worked.

Thus my own theory about why Nesfield’s Treatment worked was born.
In repeating my assertion that in the majority of cases the causes of back pain are unknown, I can almost hear various back pain experts howling me down. That, of course, is the problem. Everyone has their own different theory about what causes back pain – from orthopaedic and neurosurgeons; general practitioners, physiotherapists, acupuncturists, chiropractors, masseurs, iridologists and homeopaths.

Seeking the answer to the cause or causes of back pain is a little like trying to discover the meaning of life. Everyone has an opinion but no-one really knows.

By the time most patients reach me, my research shows they have been given an average of at least six entirely different diagnoses and six totally different treatment recommendations by at least six different experts. Understandably they are often totally confused. I ask every patient:
“What have other doctors told you is the cause of your pain?”

Note that the second most common reply given to patients after many years of suffering back pain is ‘no diagnosis’.

Many other diagnoses given to patients are both pathologically unsound and quite ridiculous:
Curved coccyx
No marrow from the lower spine down
It’s just a hell of a mess
It was caused by an accident
Tension
Neuralgia
Your bones are worn
You’re neurotic
Your pelvis is misaligned
Something’s out of place
Inflamed sinews
Strained ligament
Five nerves caught, one nerve dying
You need surgery
You’ll just have to live with it
Previously surgery has caused the pain
Your back’s buggered
It’s all in your mind

See what I mean?

No doubt each opinion has been given by a practitioner who sincerely believes that the advice is valid. Moreover, the diagnosis has been pronounced by a person, who in the patient’s eyes, often has an almost god-like aura of medical credibility and invincibility.

Back pain sufferers are extremely vulnerable human beings. They hobble, limp and crawl, or are wheeled, grim-faced into surgeries by their hundreds every day seeking expert help and advice – alleviation from their pain. Their condition is invisible and virtually indescribable. They are frequently at low ebb when they present themselves for treatment. It is not uncommon for patients to be depressed and even suicidal when they reach that stage. Many have been told they will have to live with their pain for good.

Many patients come away highly disgruntled and inappropriately treated – or not treated at all. Patients frequently feel that practitioners either do not believe their degree of pain or appear to have no concept of it. Worse, medical practitioners often appear unsympathetic to the patient’s condition, especially if the doctor suspects a malingerer seeking a compensation pay-out.
Over a period of years most chronic back pain sufferers will seek a variety of opinions and treatments until they get some degree of pain relief. Whilst most achieve pain relief at some stage, a small percentage do not and end up back where they started. They feel like they have been on a merry-go-round and the many opinions and treatments have achieved nothing. It is this group of patients that I usually see and the majority get some degree of relief following ‘Nesfield’s Treatment’.

Patients arriving in my surgery often have a less than glowing impression of doctors. I certainly try to be as understanding as possible, and as truthful. In some cases, I do not advise the patient to undertake Nesfield’s Treatment because I feel it will not benefit them, especially in cases where there are no trigger points. In many of these instances, I believe surgery may be a viable option for them and advise the patient accordingly. I seldom tell them they must live with their pain.

Conversely, where there are trigger points, I advise patients that if they undertake the treatment, they will have a 70 per cent chance of some reduction of their pain. I try not to build their expectations unrealistically and definitely not to expect a miracle cure. Nesfield’s Treatment is a more gradual process; it is usually at least a day or so, and sometimes three or four, before the patient realises the degree of pain relief gained from the treatment.

I find the initial reaction of patients curious, to say the least. Because their expectations are high, many simply expect to be cured by me, much as they would expect me to cure their respiratory infections by prescribing antibiotics, or if I was a dentist, by pulling out an infected tooth. It is a very simple approach – you are a doctor, fix me. Some expect a 100 per cent miracle cure.
I ask every patient to call me a week after I have performed the procedure on them. When they do, I inquire whether they have achieved a reduction of pain and if so, to what degree. Although a 100 per cent reduction of pain is uncommon, about 70 per cent of patients report a marked improvement in their condition. But – this is the curious part – their reactions are usually low key, or muted. Rather than yell down the line, euphorically telling me they are cured, it is usually just a matter-of-fact description of what has taken place, end of conversation.

Joy at their liberation from back pain usually comes much later, long after the treatment. I am told it often happens in private moments when people find themselves enjoying a long bushwalk, or playing tennis, or activities that were that were impossible during their regime of pain. The realisation suddenly comes to them that their lives have returned to normal and that they are free again; they feel joy then. When I hear my patient’s good news I also feel a sensation of happiness.